Resumo

RODRIGUEZ LAINZ, JL.. The omission of information in clinical histories in private medical practice as supposition of responsibility for medical malpraxis. Cuad. med. forense [online]. 2017, vol.23, n.3-4, pp.100-111.  Epub 21-Set-2020. ISSN 1988-611X.

Under the pretext of analysing a practical supposition of possible responsibility for medical malpractice in the practice of odontology, it penetrates into the analysis from the medical-legal perspective of the proper requirements of the duty to register in a medical history all relevant data that concern for the attention of a patient’s health needs. Such a duty of keeping updated a medical history has become a duty of nature as legal as deontological. Duty that finds as grounds, on one hand the guarantee of the right of every patient to clinical information; and, on the other hand, the particular needs of multidisciplinary or successive attention by medical professionals to the same patient in a hospital or health centre environment, or the potential attention to the patient by other professionals out of this realm. In fact, the only private practice of medicine doesn´t rule out this duty of keeping updated a medical history; that would continue being based precisely on the same own pillars of hospital or health centre medicine.

Failure to comply with this duty endures undoubtedly a breach of lex artis exigencies. But it does not lead necessarily to consider the fact as an offence; on not having to be recognized into the criminal justice systems mere formal breaches of legal or deontological rules related to the fulfilment of such duty of keeping updated a patients’ medical history. However, it can be the basis for constructing a possible criminal charge for recklessness; when a concrete causing harm to the patient’s health has place precisely as a representation of the risk that it was enduring that omission. In any case the option for the exercise of civil actions might find a major probability of success on the basis of the doctrines of responsibility for defective obtaining informed consent to an intervention or of the lost opportunity.

Palavras-chave : Medical malpractice; Medical history; Lex artis; Patient’s clinical information; Civil and criminal responsibility; Informed consent; Lost opportunity.

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